Provider Demographics
NPI:1851491773
Name:RANDALL, STEPHANIE LINA (RPH)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LINA
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:STEPHANIE
Other - Middle Name:LINA
Other - Last Name:HEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:36 FENGLER RD
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-8490
Mailing Address - Country:US
Mailing Address - Phone:207-883-2321
Mailing Address - Fax:207-727-5509
Practice Address - Street 1:226 PARKER FARM RD
Practice Address - Street 2:
Practice Address - City:BUXTON
Practice Address - State:ME
Practice Address - Zip Code:04093-3150
Practice Address - Country:US
Practice Address - Phone:207-727-5139
Practice Address - Fax:207-727-5509
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPS32623183500000X
MEPR0004624183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109127100Medicaid
FL109127101OtherMEDICAID DME
FL109127101OtherMEDICAID DME